Time to Renitrogenation After Maximal Denitrogenation in Healthy Volunteers in the Supine and Sitting Positions.

INTRODUCTION: Prior to intubation, preoxygenation is performed to denitrogenate the lungs and create an oxygen reservoir. After oxygen is removed, it is unclear whether renitrogenation after preoxygenation occurs faster in the supine vs the sitting position. METHODS: We enrolled 80 healthy volunteers who underwent two preoxygenation and loss of preoxygenation procedures (one while supine and one while sitting) via bag-valve-mask ventilation with spontaneous breathing. End-tidal oxygen (ETO2) measurements were recorded as fraction of expired oxygen prior to preoxygenation, at the time of adequate preoxygenation (ETO2 >85%), and then every five seconds after the oxygen was removed until the ETO2 values reached their recorded baseline. RESULTS: The mean ETO2 at completion of preoxygenation was 86% (95% confidence interval 85-88%). Volunteers in both the supine and upright position lost >50% of their denitrogenation in less than 60 seconds. Within 25 seconds, all subjects had an ETO2 of <70%. Complete renitrogenation, defined as return to baseline ETO2, occurred in less than 160 seconds for all volunteers. CONCLUSION: Preoxygenation loss, or renitrogenation, occurred rapidly after oxygen removal and was not different in the supine and sitting positions. After maximal denitrogenation in healthy volunteers, renitrogenation occurred rapidly after oxygen removal and was not different in the supine and sitting positions.

Early Intubation and Increased Coronavirus Disease 2019 Mortality: A Propensity Score-Matched Retrospective Cohort Study.

OBJECTIVES: There has been controversy about the timing and indications for intubation and mechanical ventilation in novel coronavirus disease 2019. This study assessed the effect of early intubation and mechanical ventilation on all-cause, inhospital mortality for coronavirus disease 2019 patients. DESIGN: Multicenter retrospective cohort study. SETTING: Eleven municipal hospitals in New York City from March 1, 2020, to December 1, 2020. PATIENTS: Adult patients who tested positive for coronavirus disease 2019 in the emergency department were subsequently admitted. Patients with do-not-intubate orders at admission were excluded. INTERVENTIONS: Intubation within 48 hours of triage and intubation at any point during hospital stay. MEASUREMENTS AND MAIN RESULTS: Data from 7,597 coronavirus disease 2019 patients were included; of these, 1,628 (21%) were intubated overall and 807 (11%) were intubated within 48 hours of triage. After controlling for available confounders, intubation rates for coronavirus disease 2019 patients varied significantly across hospitals and decreased steadily as the pandemic progressed. After nearest neighbor propensity score matching, intubation within 48 hours of triage was associated with higher all-cause mortality (hazard ratio, 1.30 [1.15-1.48]; p < 0.0001), as was intubation at any time point (hazard ratio, 1.62 [1.45-1.80]; p < 0.0001). Among intubated patients, intubation within 48 hours of triage was not significantly associated with differences in mortality (hazard ratio, 1.09 [0.94-1.26]; p = 0.26). These results remained robust to multiple sensitivity analyses. CONCLUSIONS: Intubation within 48 hours of triage, as well as at any time point in the hospital course, was associated with increased mortality in coronavirus disease 2019 patients in this observational study.

Emergency physician use of end-tidal oxygen monitoring for rapidsequence intubation.

BACKGROUND: End-tidal oxygen (ETO2) monitoring is used by anesthesiologists to quantify the efficacy of preoxygenation before intubation but is generally not used in emergency departments (EDs). We have previously published our findings describing preoxygenation practices in the ED during blinded use of ETO2. The purpose of this investigation is to determine whether the unblinded use of ETO2 monitoring led to improvements in preoxygenation during rapid sequence intubation in the ED and also the oxygen device or technique changes that were used to achieve higher ETO2 levels. METHODS: We conducted an interventional study at 2 academic EDs in Sydney, Australia and New York City, New York using ETO2 monitoring to investigate the preoxygenation process and effectiveness. We used data collected during a previous descriptive study for the control group, in which care teams in the same 2 EDs were blinded to the ETO2 value. In the study group, clinicians could utilize ETO2 to improve preoxygenation. Following an education process, clinicians were able to choose the method of preoxygenation and the techniques required to attempt to achieve an ETO2 level >85%. The primary outcome was the difference in ETO2 levels at the time of induction between the control and study group and the secondary outcome included the methods that were attempted to improve preoxygenation. RESULTS: A convenience sample of 100 patients was enrolled in each group. The median ETO2 level achieved at the time of induction was 80% (interquartile range 61 to 86, overall range 73) in the control group and 90% in the study group (interquartile range 83 to 92, overall range 41); the median difference was 12 (95% confidence interval: 8, 16, P = < 0.001). The majority of oxygen device changes were from non-rebreather mask to bag-valve-mask (BVM) (15%, n = 15) and changes in technique from improvements in mask seal (54%, n = 34). The final device used in the study group was BVM in 87% of cases. CONCLUSIONS: In 2 clinical studies of ETO2 in academic EDs, we have demonstrated that the use of ETO2 is feasible and associated with specific and potentially improved approaches to preoxygenation. A clinical trial is needed to further study the impact of ETO2 on the preoxygenation process and the rate of hypoxemia.

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED's Experience During the COVID-19 Pandemic.

OBJECTIVE: Prolonged and unaddressed hypoxia can lead to poor patient outcomes. Proning has become a standard treatment in the management of patients with ARDS who have difficulty achieving adequate oxygen saturation. The purpose of this study was to describe the use of early proning of awake, non-intubated patients in the emergency department (ED) during the COVID-19 pandemic. METHODS: This pilot study was carried out in a single urban ED in New York City. We included patients suspected of having COVID-19 with hypoxia on arrival. A standard pulse oximeter was used to measure SpO2 . SpO2 measurements were recorded at triage and after 5 minutes of proning. Supplemental oxygenation methods included non-rebreather mask (NRB) and nasal cannula. We also characterized post-proning failure rates of intubation within the first 24 hours of arrival to the ED. RESULTS: Fifty patients were included. Overall, the median SpO2 at triage was 80% (IQR 69 to 85). After application of supplemental oxygen was given to patients on room air it was 84% (IQR 75 to 90). After 5 minutes of proning was added SpO2 improved to 94% (IQR 90 to 95). Comparison of the pre- to post-median by the Wilcoxon Rank-sum test yielded P = 0.001. Thirteen patients (24%) failed to improve or maintain their oxygen saturations and required endotracheal intubation within 24 hours of arrival to the ED. CONCLUSION: Awake early self-proning in the emergency department demonstrated improved oxygen saturation in our COVID-19 positive patients. Further studies are needed to support causality and determine the effect of proning on disease severity and mortality.

Behind the Scenes of Successful Research in Emergency Medicine: Nine Tips for Junior Investigators.

Education related to clinical research often focuses on methodology, statistics, ethics, and study design. While knowledge of these conventional skills is essential to the operationalization of research, many "soft" skills related to leadership, communication, and team management are critical to the successful conduct research in the real world. Conducting clinical research in the emergency department is generally a challenging endeavor. Based on our prior experience as clinical researchers and a narrative review of the published literature, we offer nine practical strategies to help junior investigators conduct research. To successfully execute a research study, investigators must know how to motivate their team, create a brand around their study, communicate effectively, maximize clinician and patient engagement, and celebrate victory, among other skills. These skills and strategies are often missing from the formal research education and in peer-reviewed manuscripts but are, in fact, invaluable to the successful development of junior investigators. Thus, we offer the "story behind the study" in an effort to contribute to research education with material that is not typically covered in formal curricula.

Novel Use of a Gas Analyzer Can Reliably Predict the Arterial Oxygen among Emergency Department Patients Undergoing Rapid Sequence Intubation.

BACKGROUND: To our knowledge, no study has assessed the correlation of fraction of inspired oxygen (FiO2) and end-tidal oxygen (EtO2) values obtained from a gas analyzer during the preoxygenation period of rapid sequence intubation (RSI) to predict partial pressure of oxygen (PaO2) among patients requiring intubation in the emergency department (ED). OBJECTIVE: The purpose of this study was to determine whether a simple equation using EtO2 and FiO2 at time of induction could reliably estimate minimal PaO2 in ED patients undergoing RSI. METHODS: We conducted an observational pilot study performed in an adult ED utilizing a gas analyzer to obtain EtO2 and FiO2 values in ED patients undergoing RSI from data collectors blinded to our objective. The Pearson correlation coefficient was calculated between the equation's predicted PaO2 and the PaO2 drawn from an arterial blood gas shortly after intubation. A Bland-Altman plot analysis was performed to identify any additional bias. RESULTS: Seventy-five patients were enrolled. The equation's mean predicted minimal PaO2 and mean PaO2 from an arterial blood gas within 3 min after intubation was 178 mm Hg (95% confidence interval [CI] 145-211 mm Hg) and 209 mm Hg (95% CI 170-258 mm Hg), respectively. The Pearson correlation coefficient between the predicted minimal PaO2 and post-intubation PaO2 demonstrated a strong correlation (r2 = 0.89). The Bland-Altman plot indicated no bias affecting the correlation between the predicted and actual PaO2. CONCLUSIONS: Among ED patients undergoing RSI, the use of a gas analyzer to measure EtO2 and FiO2 can provide a reliable measure of the minimal PaO2 at the time of induction during the RSI phase of preoxygenation.

Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department.

STUDY OBJECTIVE: Preoxygenation is important to prevent oxygen desaturation during emergency airway management. The purpose of this study is to describe the use of end tidal oxygen (eto2) during rapid sequence intubation in the emergency department. METHODS: This study was carried out in 2 academic centers in Sydney, Australia, and New York City. We included patients undergoing rapid sequence intubation in the emergency department. A standard gas analyzer was used to measure eto2. Preoxygenation methods included nonrebreather mask and bag-valve-mask ventilation. We measured eto2 before preoxygenation and at administration of rapid sequence intubation medications. We also characterized peri-intubation SpO2, identifying instances of SpO2 less than 90%. RESULTS: We included 100 patients during a 6-month period. Median eto2 level before and after preoxygenation was 53% (interquartile range [IQR] 43% to 65%) and 78% (IQR 64% to 86%), respectively. One fourth of patients achieved an eto2 level greater than 85%. Median eto2 level achieved varied with preoxygenation method, ranging from 80% (IQR 60% to 87%) for the nonrebreather mask group to 77% (IQR 65% to 86%) for the bag-valve-mask group. The method with the highest median eto2 level was nonrebreather mask at flush rate (86%; IQR 80% to 90%) and the lowest median eto2 level was nonrebreather mask at 15 L/min (57%; IQR 53% to 60%). Eighteen patients (18%) experienced oxygen desaturation (SpO2 <90%); of these, 14 (78%) did not reach an eto2 level greater than 85% at induction. CONCLUSION: ETO2 varied with different preoxygenation techniques employed in the emergency department. Most patients undergoing rapid sequence intubation did not achieve maximal preoxygenation. Measuring ETO2 in the emergency department may be a valuable adjunct for optimizing preoxygenation during emergency airway management.

Respiratory adjusted shock index for identifying occult shock and level of Care in Sepsis Patients.

OBJECTIVE: Early identification of shock allows for timely resuscitation. Previous studies note the utility of bedside calculations such as the shock index (SI) and quick sepsis-related organ failure assessment (qSOFA) to detect occult shock. Respiratory rate may also be an important marker of occult shock. The goal of our study was to evaluate whether using a modified SI with respiratory rate would improve identification of emergency department sepsis patients admitted to an ICU or stepdown unit. METHODS: A prospective, observational cohort study of the respiratory adjusted shock index (RASI), defined as HR/SBP × RR/10, was conducted. RASI was calculated from triage vital signs and compared to serum lactate. Primary outcome was admission to a higher level of care defined as ICU or stepdown unit. A multivariable logistic regression model including RASI, SI, lactate, age and sex was performed with disposition as the outcome variable. Areas under the curve (AUC) were calculated to detect occult shock and level of care for RASI, SI, and qSOFA. RESULTS: 408 patients were enrolled, 360 were included in the analysis. Regression analysis revealed that lactate (OR 1.55, z = 4.38, p < 0.0001) and RASI (OR 2.27, z = 3.03, p < 0.002) were predictive of need for higher level of care. The AUC for RASI, SI, and qSOFA to detect occult shock were 0.71, 0.6, and 0.61 respectively. RASI also had a significant AUC in predicting level of care at 0.75 compared to SI (0.64) and qSOFA (0.62). CONCLUSIONS: RASI may have utility as a rapid bedside tool for predicting critical illness in sepsis patients.

Do Out-of-Hospital Cardiac Arrest Patients Have Increased Chances of Survival When Transported to a Cardiac Resuscitation Center?

Background Patients suffering from an out-of-hospital cardiac arrest are often transported to the closest hospital. Although it has been suggested that these patients be transported to cardiac resuscitation centers, few jurisdictions have acted on this recommendation. To better evaluate the evidence on this subject, a systematic review and meta-analysis of the currently available literature evaluating the association between the destination hospital's capability (cardiac resuscitation center or not) and resuscitation outcomes for adult patients suffering from an out-of-hospital cardiac arrest was performed. Methods and Results PubMed, EMBASE , and the Cochrane Library databases were first searched using a specifically designed search strategy. Both original randomized controlled trials and observational studies were considered for inclusion. Cardiac resuscitation centers were defined as having on-site percutaneous coronary intervention and targeted temperature management capability at all times. The primary outcome measure was survival. Twelve nonrandomized observational studies were retained in this review. A total of 61 240 patients were included in the 10 studies that could be included in the meta-analysis regarding the survival outcome. Being transported to a cardiac resuscitation center was associated with an increase in survival (odds ratio=1.95 [95% confidence interval 1.47-2.59], P<0.001). Conclusions Adult patients suffering from an out-of-hospital cardiac arrest transported to cardiac resuscitation centers have better outcomes than their counterparts. When possible, it is reasonable to transport these patients directly to cardiac resuscitation centers (class II a, level of evidence B, nonrandomized). Clinical Trial Registration URL : www.crd.york.ac.uk/PROSPERO/ . Unique identifier: CRD 42018086608.

Peri-intubation factors affecting emergency physician choice of paralytic agent for rapid sequence intubation of trauma patients.

INTRODUCTION: No study has assessed predictors of physician choice between the succinylcholine (Succ) and rocuronium (Roc) for rapid sequence intubation (RSI) during the initial resuscitation of trauma patients in the emergency department (ED). METHODS: We retrospectively evaluated of the use of Succ and Roc for adult trauma patients undergoing RSI at a Level 1 trauma center. The primary outcome was to identify factors affecting physician choice of paralytic agent for RSI analyzed by cluster analysis using pre-intubation vital signs and early mortality. The secondary outcome was to identify factors influencing physician choice of paralytic agent using a logistic regression model reported as adjusted odds ratios (aOR). RESULTS: The analysis included 215 patients, including 148 receiving Succ and 67 receiving Roc. The two groups were similar in regard to age, provider level of training, mean GCS (10 vs. 10) and median ISS (27 vs. 27). Cluster analysis using peri-intubation patient vital signs and early mortality indicates that patients with predominantly abnormal vital signs and early mortality were more likely to receive Roc (74%) than those without abnormal vital signs prior to intubation or early mortality (24%). Hypoxemia prior to RSI (aOR 12.3 [2.5-60.9]) and the use of video laryngoscopy (VL) (aOR 5.5 [1.2-24.6]) were associated with the choice to use Roc. CONCLUSIONS: Roc was more frequently chosen for paralysis in the patient cluster with predominantly abnormal peri-intubation vital signs and higher rate of early ED mortality. The use of Roc was associated with hypoxemia prior to RSI and VL.

Waveform capnography: an alternative to physician gestalt in determining optimal intubating conditions after administration of paralytic agents.

PURPOSE: We sought to evaluate the utility of waveform capnography (WC) in detecting paralysis, by using apnoea as a surrogate determinant, as compared with clinical gestalt during rapid sequence intubation. Additionally, we sought to determine if this improves the time to intubation and first pass success rates through more consistent and expedient means of detecting optimal intubating conditions (ie, paralysis). METHODS: A prospective observational cohort study of consecutively enrolled patients was conducted from April to June 2016 at an academic, urban, level 1 trauma centre in New York City. Nasal cannula WC was used to determine the presence of apnoea as a surrogate measure of paralysis versus physician gestalt (ie, blink test, mandible relaxation, and so on). RESULTS: One hundred patients were enrolled (50 in the WC group and 50 in the gestalt group). There were higher proportions of failure to determine optimal intubating conditions (ie, paralysis) in the gestalt group (32%, n=16) versus the WC group (6%, n=3), absolute difference 26, 95% CI 10 to 40. Time to intubation was longer in the gestalt group versus the WC group (136 seconds vs 116 seconds, absolute difference 20 seconds 95% CI 14 to 26). First pass success rates were higher in the WC group verses the gestalt group (92%, 95% CI 85 to 97 vs 88%, 95% CI 88 to 95, absolute difference 4%, 95% CI 1 to 8). CONCLUSION: These preliminary results demonstrate WC may be a useful objective measure to determine the presence of paralysis and optimal in tubating conditions in RSI.

The effect of the apneic period on the respiratory physiology of patients undergoing intubation in the ED.

OBJECTIVES: We sought to examine the physiological impact the apneic period has on the respiratory physiology of patients undergoing intubation in the emergency department and whether DAO, the delivery of 15L oxygen by nasal cannula during apnea, can affect the development of respiratory acidosis. METHODS: This was a prospective observational cohort study conducted at an urban academic level 1 trauma center. A convenience sample of 100 patients was taken. Timed data collection forms were completed during the periintubation period. We report the mean ABG and end-tidal CO2 (EtCO2) values between those with normal and prolonged apnea times (>60s) and between those who received DAO and those who did not. RESULTS: 100 patients met our inclusion criteria. There were no significant differences in the pre-RSI ABG values between those who received DAO and those who did not and between those with apnea times less than or >60s. Only in the group of patients with apnea times >60s did significant changes in respiratory physiology occur. DAO did not alter the trend in respiratory acidosis during the periintubation period. EtCO2 increased as apnea times were prolonged, and DAO altered this trend. CONCLUSIONS: Post-RSI EtCO2 increased as apnea times were prolonged. DAO may alter this trend. Statistically significant changes in pH and PaCO2 (mean differences of 0.15 and 12.5, respectively) occurred in the group of patients who had mean apnea times of >60s but not in those with apnea times <60s.

Twenty-four-hour packed red blood cell requirement is the strongest independent prognostic marker of mortality in ED trauma patients.

BACKGROUND: Injury severity score, serum lactate, and shock index help the physician determine the severity of injuries present and have been shown to relate to mortality. We sought to determine if an increasing amount of packed red blood cells (PRBCs) given in the first 24hours of admission is an independent predictor of mortality and how it compares to other validated markers. METHODS: A 6-year retrospective, observational study of adult trauma patients was conducted at a level 1 trauma center. Charts were reviewed for demographic data, amount of PRBC received in the first 24hours, injury severity score, shock index, and lactate levels. Subgroups were used to determine if each variable was an independent predictor of mortality. Correlation coefficients and linear regression were used to determine the strength of correlation between each variable and mortality. RESULTS: One hundred fifty-seven patients met criteria over a 6-year period. The average age was 28years, 93% were male, and 86% had penetrating injuries. The average injury severity score, serum lactate, and shock index were 18, 6.1, and 0.9, respectively. The average amount of blood given was 6.7 U. CONCLUSION: Twenty-four-hour PRBC requirement is both a novel independent predictor of and has the greatest correlation to mortality in adult trauma patients when compared to injury severity score, shock index, and serum lactate.

Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED.

BACKGROUND: Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) have been shown to be of use in determining shock in patients with seemingly normal vital signs. We seek to determine if these biomarkers can be used interchangeably in patients with trauma in the emergency setting based on their test characteristics and correlation to each other. METHODS: A prospective observational cohort study was undertaken at an urban level 1 trauma center. Baseline vital signs, point-of-care BE, AG, and serum lactate were recorded in all patients who presented for trauma. Correlation was determined by linear regression model. Overall test characteristics and relative risk were calculated. RESULTS: One hundred patients were enrolled. The median age was 30 years (interquartile range, 24-42 years), and 89% were male. Fifty-three percent of injuries were blunt trauma. Pearson correlation of serum lactate to BE was -0.81 (r(2) = 0.66; 95% confidence interval [CI], 0.53-0.75; P < .001), that of BE to AG was -0.71 (r(2) = 0.5; 95% CI, -0.80 to -0.57; P < .01), and that for serum lactate to AG was 0.71 (r(2) = 0.5; 95% CI, 0.57-0.80; P < .01). CONCLUSIONS: This study demonstrates that the biomarkers have similar test characteristics which may make them interchangeable as indicators for the presence of occult shock in patients with trauma. Lactate and BE correlate well with each other; however, AG was not as strongly correlated with either.

Determining the utility of metabolic acidosis for trauma patients in the emergency department.

BACKGROUND: Metabolic acidosis has been proposed as the gold standard to define shock in trauma patients. Other studies determine the presence of shock by use of serum lactate. However, not all medical centers have the ability to utilize point-of-care lactate at bedside. OBJECTIVE: This study seeks to determine the relationship between serum lactate and metabolic acidemia in trauma patients, and if metabolic acidemia can be used to guide therapy. We hypothesized that acidemia would be strongly correlated with lactate levels and would be associated with activation of massive transfusion (MT) in the presence of shock in trauma. METHODS: This was a prospective observational cohort study, level II evidence; this study aids in decision-making. Setting was a Level I academic, urban trauma center. The study took place from July 1, 2012 to March 1, 2013 and included patients who were ≥18 years old and required trauma team activation. Observations included baseline demographics (age, gender, type of injury), vital signs, point-of-care arterial blood gas, lactate, and need for MT. RESULTS: One hundred patients were enrolled over the study period. The average age was 34 years, and 82% were male. Forty patients were acidemic (pH < 7.35), and there was a significant difference in lactate levels between the acidemic and non-acidemic groups (p < 0.002). We found a strong correlation between pH and lactate: rs = -0.38, t = -4.03, p < 0.001. In addition, using a logistic regression, we show that pH was associated with activation of MT (p = 0.002). CONCLUSION: This is a prospective observational cohort study with level II evidence. This study demonstrates that acidemia was strongly correlated to serum lactate, lactate levels were higher in the acidemic group, and metabolic acidemia was associated with the activation of MT for trauma patients at our institution.

Placement of a central venous catheter in the antecubital vein using a modified seldinger technique.

PURPOSE: To describe a case of a patient requiring inotropic support without central venous access in which the central venous catheter (CVC) was placed in the antecubital vein using a modified seldinger technique. BACKGROUND: Placement of CVC in the field in retrieval medicine can be time consuming and is not without risk of complication. Minimizing time in the field can lead to better outcomes for patients who are seriously medically ill or traumatically injured. The ED also offers a more controlled environment for the safe and accurate placement of CVCs. However, there are times in the prehospital environment when more secure access than peripheral is needed in order to administer the appropriate treatment. Herein, a modified seldinger technique is described for the peripheral placement of a CVC. CASE REPORT: A 53-year-old man presented to a remote health clinic in the outback of Australia with complaints of weakness, persistent vomiting and chest pain. He subsequently arrested for a brief period (∼3 minutes) from suspected hyperkalemia complicated by MI and upon resuscitation was bradycardic, obtunded and hypotensive. Clinic staff were only able to gain an 18G left antecubital IV. The patient required an adrenaline infusion, IVF and other medications. Using the angiocatherter already in place, a guide wire was placed through and a quadruple lumen CVC was placed without complication allowing for infusion of medications (adrenaline drip, meropenem) and IVF. The catheter was removed after a CVC was placed under US guidance and sterile conditions in the ICU 12 hours later. CONCLUSION: This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.